1. Mr. SJ, a 54-year-old male, presented with left knee pain, swelling, and stiffness for 2 days. Physical exam found swelling, redness, warmth, and limited range of motion in the left knee.
2. Laboratory tests found elevated uric acid at 8.2 mg/dl. X-ray and synovial fluid analysis were planned to evaluate for gout arthritis versus osteoarthritis.
3. The patient was diagnosed with acute gout arthritis and prescribed a low purine diet, colchicine, allopurinol, and paracetamol to manage the attack and reduce uric acid levels long-term to prevent future attacks.
1. Mr. SJ, a 54-year-old male, presented with left knee pain, swelling, and stiffness for 2 days. Physical exam found swelling, redness, warmth, and limited range of motion in the left knee.
2. Laboratory tests found elevated uric acid at 8.2 mg/dl. X-ray and synovial fluid analysis were planned to evaluate for gout arthritis versus osteoarthritis.
3. The patient was diagnosed with acute gout arthritis and prescribed a low purine diet, colchicine, allopurinol, and paracetamol to manage the attack and reduce uric acid levels long-term to prevent future attacks.
1. Mr. SJ, a 54-year-old male, presented with left knee pain, swelling, and stiffness for 2 days. Physical exam found swelling, redness, warmth, and limited range of motion in the left knee.
2. Laboratory tests found elevated uric acid at 8.2 mg/dl. X-ray and synovial fluid analysis were planned to evaluate for gout arthritis versus osteoarthritis.
3. The patient was diagnosed with acute gout arthritis and prescribed a low purine diet, colchicine, allopurinol, and paracetamol to manage the attack and reduce uric acid levels long-term to prevent future attacks.
1. Mr. SJ, a 54-year-old male, presented with left knee pain, swelling, and stiffness for 2 days. Physical exam found swelling, redness, warmth, and limited range of motion in the left knee.
2. Laboratory tests found elevated uric acid at 8.2 mg/dl. X-ray and synovial fluid analysis were planned to evaluate for gout arthritis versus osteoarthritis.
3. The patient was diagnosed with acute gout arthritis and prescribed a low purine diet, colchicine, allopurinol, and paracetamol to manage the attack and reduce uric acid levels long-term to prevent future attacks.
Download as PPTX, PDF, TXT or read online from Scribd
Download as pptx, pdf, or txt
You are on page 1/ 31
CASE REPORT
GOUT ARTHRITIS PATIENT’S IDENTITY
Name : Mr. SJ Age : 54 years old HISTORY TAKING Main Complaint : Pain in the left knee Present History : • Male, 54 years old consulted from endocrine with type 2 DM and suspect gout in the left knee. • Patient complain of pain in his left knee since 2 days ago, accompanied with stiffness less than 30 minutes of the left knee experienced in the morning which make it difficult for patient to wake and stand up, swelling and redness also founded in the left knee, and the patient felt the pain with touch or pressured to the affected joint. There is also puffiness around the bony parts of the swollen left knee that appears prominent when compared with the right knee. • There is history of coto and meatballs consumption last week. • A history of frequent pain and swelling experienced since 1 year ago, there was also a history of pain in the joint of the big toe, so the patient came at the pharmacy to check her uric acid, and the result of his uric acid levels is 11. HISTORY TAKING • Then the patient was given some drugs, which were allopurinol 100 mg 1x1, dexamethasone 0.75 mg 1x1, and Na diclofenac 25 mg. Patient consume the drugs only if pain and swelling in the knee arise, the last time patient taking the drug was last week. • There is history of DM since 1 year ago and given insulin. There is also a history of hypertension. • No history of heavy activity. Defecation and urination normal, there is no stone found in the urine. PHYSICAL EXAMINATION General Description General condition : Moderate illness Nutrition : Normoweight - Height : 168 cm - Weight : 60 kg - BMI : 21.2 kg/m2
Vital Signs - Awarness: Conscious (GCS 15) - Blood pressure : 170/90 - Heart rate : 84 x/minutes, regular - Respiratory rate: 20 x/minutes - Temperature : 37°C - VAS (numerical) : 4/10 PHYSICAL EXAMINATION • Head : Normocephal, not easy to remove • Face : Normal • Eyes : Pupils isochor, conjunctiva not anemic, sclera not icterus • Ear : No abnormalities, otorrhea (-) • Nose : No abnormalities, secret (-) • Oral cavity : No abnormalities • Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1
• Neck : JVP R+0 cm H2O, no lymphadenopathy, no deviation of the
trachea. PHYSICAL EXAMINATION • Lung • Inspection: Symmetrical left and right • Palpation : Focal fremitus normal • Percussion : Sonor • Auscultation: Vesicular breathing sounds, wheezing (-), ronchi (-) • Heart • Inspection: Ictus cordis not seen • Palpation : Ictus cordis palpable at ICS V linea midclavicularis • Percussion : Dull, left heart border linea midclavicularis • Auscultation : Heart sound I / II regular, no murmur • Abdomen • Inspection: Convex • Auscultation : Bowel peristalsis (+) normal • Palpation : Liver and spleen not palpable • Percussion : Tympani RHEUMATOLOGICAL STATUS
• Gait : Antalgic gait
• Arm : Normal • Leg : • Genu sinistra : rubor (+), calor (+), dolor (+), crepitation (+), effusion (+), bulge sign, tenderness (+), and limited ROM (+) • Spine : Normal LABORATORY FINDING Laboratorium Result
Parameter Results Normal value
WBC 15600 µL 4000-10000/µL
RBC 4.97 x 106 µL 4.0 – 6.0 x 106 /µL
HGB 13.7 g/dL 12.0 – 16.0 g/dL
HCT 40.0 % 37.0 – 48.0 %
PLT 345000 µL 150000 – 400000 /µL
Neutrofil 85.0 % 52.0 – 75.0 %
Lymphosit 12.6 % 20.0 – 40.0 %
Monosit 11.4 % 2.00 – 8.00 %
LABORATORY FINDING Parameter Results Normal value Ureum 24 10-50 mg/dl
Creatinin 1.62 L <1.3, P <1.1 mg/dl
Uric Acid 8.2 mg/dl L 3.4-7.0, P 2.45-5.7 mg/dl
eGFR 47.4 g/dl ≥ 90 gr/dl
GDP 194 mg/dl 110 mg/dl GD2PP 263 mg/dl < 200 mg/dl HBA 1c 13.9 % 4–6% PROBLEM LIST Assessment Planning Diagnostic Planning Therapy
1. Acute Gout Arthritis Urine uric acid 24 hours • Low purin diet Pain in the left knee Synovial fluid analysis • Colchisine Based on ACR/EULAR for Gout 2015: 0,5mg/6hrs/oral • Pattern of joint/bursa involvement • Allopurinol during symptomatic episode in the 100mg/24hrs/oral knee and mtp 1 (2) • Paracetamol • Erythema overlying affected joint, 1000mg/6hrs/oral can’t bear touch or pressure to affected joint, and great difficulty with walking or inability to use affected joint (3) • Serum urate 8.2 mg/dl (3) PROBLEM LIST Assessment Planning Diagnostic Planning Therapy
DD/Secondary (avoid trauma) Pain in the left knee • Physical therapy Knee effusion • Paracetamol Based on ACR/EULAR 2015: 1000mg/6hrs/oral • Age >50 years • Arthrosentesis • Morning stiffness <30 minutes • Joint crepitus on active motion 3. Hypertension Grade II Blood pressure : 170/90 4. Diabetes Mellitus Blood pressure : 170/90 PROBLEM LIST Assessment Planning Diagnostic Planning Therapy
DD/Secondary (avoid trauma) Pain in the left knee • Physical therapy Knee effusion • Paracetamol Based on ACR/EULAR 2015: 1000mg/6hrs/oral • Age >50 years • Arthrosentesis • Morning stiffness <30 minutes • Joint crepitus on active motion DISCUSSION What is Gouty Arthritis?
- Form of arthritis caused by having sodium
urate crystals in the joint space. - Painful and can also swelling in a joint - Most commonly affects the joint in the first metatarsophalangeal joint Risk Factor • Hyperuricemia • Drugs • Male sex Diuretic • Chronic renal failure • Hypertension • Foods high in purine • Obesity Meat • Coronary heart disease Seafood • Diabetes • Dyslipidemia • Alcohol and high-sugar soft drinks • Metabolic syndrome
Adapted from Khanna D, Arthritis Care Res 2012;64(10):1431-46; Zhang et al, Ann Rheum Dis 2006;65:1301-11; Neogi T, N Engl J Med 2011;364(5):443-52 Urid Acid Metabolism
Dennis A, et al. Pathogenesis of Gout. Annals of Internal Medicine. 2005; 143(7): 505 Pathophysiology of Gout
G Ragab et al. Gout: An Old Disease in New Perpective. Journal of Advanced Research 8. 2017; 495-511 Pathophysiology of Gout
Dennis A, et al. Pathogenesis of Gout. Annals of Internal Medicine. 2005; 143(7): 503 4 Stages of Gout
Asymptomati Chronic Acute Gout IntercriticalSt cHyperurice Stadium with Arthritis adium mia Tophus Clinical Manifestation
GOUTY ARTHRITIS
Hyperuricemia The history of gout begins with swelling on the first Metatarsophalangeal joint. Clinical symptoms : Also knee and elbow Rapid onset of pain, starts at night, swelling, redness, A habit of eating seafood and warmth does not restrict the food.
IPD How to Diagnose? 2015 ACR/EULAR Gout Classification Criteria How to Diagnose? 2015 ACR/EULAR Gout Classification Criteria Management Therapy
MANAGEMENT THERAPY
NON PHARMACOLOGICAL PHARMACOLOGICAL
NON PHARMACOLOGICAL
- Reduce body weight until ideal
- Lower purin diet - Rest the joint - Avoid drugs that causes increase urid acid level
Panduan Praktis Klinis Reumatologi
Non Pharmocological : Healthy Diet Pharmacological ACUTE STAGE
• Colchicine 3-4 times dose 0.5-0.6 mg /day
(max. 6 mg)
• NSAIDs
• Steroid (oral, IM or intra articular)
INTERCRITICAL AND CRONIC STAGE
Hyperuricemic medicine • Xanthine Oxidase Inhibitors (Allopurinol) initial dose of 1x100 mg / day. Dosage may be increased to 900 mg / day. • Probenecid 2x 250 -500 mg / day Prevention of attacks: • Colchicine dose 0.5 mg / 6hours • Low dose steroids Based on Uric Acid 24 hours
• Normal : L = 3.4-7.0 mg/dl
P = 2.45-5.7 mg/dl
• Underproduction : • Drugs : Probenesid (Allopurinol) initial dose of 1x100 mg / day. Dosage may be increased to 900 mg / day.
• Overproduction : • Drugs : Allopurinol 2x 250 -500 mg / day THANK YOU
